Pharmacist prescribing
Views on why pharmacists should prescribe, what training
they should receive, how supplementary prescribing will work in practice
and what
legal responsibilites prescribing brings were all presented at the seventh
annual Hospital Pharmacist conference held in London on 30 October. Gareth
Jones and
Rachel Graham (on the staff of Hospital Pharmacist) report
Dr June Crown: supplementary prescribing by pharmacists will make things better for patients, pharmacists and the National Health Service |
How we got where we are, and where we go from here, were
the focus of the opening presentation, given by Dr JUNE CROWN, chair
of the Royal Pharmaceutical Society’s task group team that looked
into extended role prescribing for pharmacists.
Dr Crown took delegates down the route to supplementary prescribing,
through the reviews and legislative processes that had led first to nurse
prescribing and then to pharmacist prescribing. She pointed out that
the process had initially been slow. The advisory group for nurse prescribing
was formed back in 1989, legislation was put in place in 1992, but national
roll-out did not happen until 1998. According to Dr Crown, much of the
delay was because of pilots and economic appraisals being carried out.
The process then speeded up, with pharmacist prescribing being recommended
in a report published as a consultation document in 1999, and legislation
(Health and Social Care Act) being enacted in 2001. Confidence had built
up for pharmacist prescribing, Dr Crown said, and there was a robust
approach to taking it forward.
Panel 1: Definitions
Supplementary prescribing
A voluntary partnership between an independent prescriber and a supplementary
prescriber, to implement an agreed patient-specific clinical management
plan with the patient’s agreement
Independent prescriber
A clinician who is responsible for the assessment of patients with
an undiagnosed condition and for decisions about the clinical management
required, including prescribing
Supplementary prescriber
A clinician who takes over the continuing care of a patient, which
may include prescribing, after initial assessment by an independent
prescriber |
Dr Crown also took delegates through the definitions of supplementary
prescribing, supplementary prescriber and independent prescriber under
the legislation (see Panel 1, p474). She pointed out that this final
definition of a supplementary prescriber is wide-reaching. It has been
changed from that in the consultation document issued by the Department
of Health to make it clear that, for example, the supplementary prescriber
(as well as the independent prescriber) has responsibilities for their
prescribing. The definition could cover, for example, the situation where
a doctor diagnoses a patient’s condition and then hands over the
management to the pharmacist. How this would work in practice (ie, whether
hospital notes could constitute a clinical management plan) needs to
be ironed out, Dr Crown added. But the definition of supplementary prescriber
itself is wide enough to accommodate this sort of working arrangement.
Dr Crown then went on to discuss the benefits of supplementary prescribing
for patients, pharmacists and organisations. She was keen to stress that
she saw the main reasons behind the recommendations to extend prescribing
to pharmacists as benefiting patients and making better use of the skills
of the workforce. From her point of view, “it is not about plugging
the gaps of too few doctors”.
Patients will benefit from supplementary prescribing in that it offers
them improved access to health care staff and greater convenience, as
well as increased choice, she said. “Time taken in explaining to
patients about their medication … is hugely important,” she
said. In particular, Dr Crown sees pharmacist prescribing as being especially
useful in, for example, anticoagulant and hypertension management, where
pharmacists are already essentially running clinics. She also sees it
as being invaluable in the mental health field, because it may be “tremendously
important in improving ... compliance”.
Pharmacists benefit from supplementary prescribing because it brings
them clearer lines of responsibility and accountability, the opportunity
to work more effectively in a multidisciplinary team and recognition
from team members, Dr Crown said. Organisations benefit from the better
use of skills.
Pharmacist prescribing should also help the Government to reduce health
care inequalities, Dr Crown added. Allowing pharmacists to prescribe
at public expense would help the vulnerable, she stressed. However, she
suspected that there would be cost implications – particularly
since many people with the chronic conditions that supplementary prescribing
arrangements are set up to treat are over 60, and so get free prescriptions.
Despite the wide number of activities that pharmacists could perform
as supplementary prescribers, Dr Crown believes there are occasions when
pharmacists being able to independently prescribe would be of benefit
to patients. For hospital-based practice, these included prescribing
on admission and discharge, where arrangements might need to be changed.
Accident and emergency pharmacists might also be well placed to prescribe
independently in medicine-related emergencies, she said. Dr Crown was
keen to point out that pharmacists are already independent prescribers
in as much as they “prescribe” general
sales list and pharmacy-only medicines, as well as certain prescription-only
medicines in an emergency, in the community.
During her speech, Dr Crown discussed the information that pharmacist
prescribers (in common with all prescribers) will need to perform their
role effectively. This includes timely information about the patients’ clinical
condition and the medicines they are already taking. How they will get
this information is also crucial, she said. She urged the Government
to bring about the promised and much needed improvements in NHS information
technology. In the meantime, Dr Crown stressed, pharmacists will need
to think for themselves about making sure safe arrangements are put in
place.
She also stressed that patients and the public need information too – they
need to know which professionals are authorised to prescribe, which conditions “new” prescribers
can treat, and how to access services. Government and professional bodies
have a role in this. Crucially, patients also need to be aware that they
have a choice – if they prefer a doctor to prescribe their medicines
then they are entitled to ask for this. Similarly, patients need to know
that all the options they have as to who can prescribe their medicines
are safe and well regulated. Dr Crown stressed that pharmacists need
to make the public aware that they are the “absolute experts in
medicines” rather than just people who “take a blister pack
off a shelf and hand it to them”. A recent Health Which report
highlighted this.
As well as independent prescribing for pharmacists, Dr Crown saw the
future of prescribing in the NHS as including health care professionals
other than doctors, nurses and pharmacists. But only those professions
where there is a registerable qualification and a regulatory body will
be considered, Dr Crown said. There is commitment from the Government
to extend prescribing beyond nurses and pharmacists (and doctors), Dr
Crown added. She is certain that by that this time next year other health
care professionals will be “well on their way”.
For pharmacist prescribing, key considerations in moving forward include
whether prescribing will become part of school of pharmacy curricula,
how pharmacists can keep up to date with new clinical and pharmacological
developments once they have done their initial training, issues about
the diagnostic skills needed to prescribe independently, and how supplementary
prescribing will affect their relationship with other members of the
health care team. It will also be important to consider how the benefits
of supplementary prescribing can be demonstrated to the Government, patients
and other professionals. “Rather than waiting for the Government
to make assumptions,” Dr Crown said, “it will be up to pharmacists
to take the lead in deciding the answers.” |
